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Sunday, 28 December 2014

Among the metabolites the Malassezia synthesizes is pityriacitrin
that absorbs ultraviolet (UV) light. The
hypopigmentation is accentuated if the surrounding unaffected skin becomes
tanned.

Patients should be informed that the hypopigmentation will
take time to resolve and is not a sign of treatment failure. Repigmentation may take several months even
when the organisms have been destroyed. After the fungal disease is cured, an effort can
be made to regain the lost pigmentation through UV light exposure. Prevention of recurrence is also important.

The patient chose to shorten the time needed for
repigmentation by receiving UV light sessions.

Friday, 7 November 2014

Once considered a tuberculoid reaction, lichen nitidus (Latin
nitidus, shiny) is currently regarded as a disorder of unknown aetiology.
However, history of exposure to tuberculosis in the “setting of lichen nitidus”
should be investigated and when appropriate antituberculosis treatment is initiated.
Actually, lichen nitidus needs to be
distinguished from lichen scrofulosorum. While the infiltrate in lichen nitidus
‘hugs’ the epidermis and expands the dermal papilla, the granulomas in lichen scrofulosorum do not cause widening of the papillae. Furthermore, in lichen scrofulosorum,
there may be mild spongiosis and exocytosis of neutrophils into the epidermis
and the granulomas are typically centred on the
hair follicles or sweat ducts.

An “allergen” may cause antigen-presenting cells to activate a
cell-mediate response, initiate lymphocyte accumulation, and form the discrete
papules. Actually, Langerhans cells are
present in large numbers in the infiltrate. Cytokines may shift the T
lymphocyte response towards the T helper (CD4+) 2 subset that has the potential
to produce the superficial dermal granulomas seen in lichen nitidus (in
comparison, CD8+ lymphocytes play an important role in lichen planus (LP) where
there are no granulomas). At each lateral margin of the infiltrate, rete ridges
tend to extend downwards and seem to clutch the infiltrate in the manner of a
claw clutching a ball. Direct immunofluorescence
examination of lichen nitidus is usually negative (in comparison, direct immunofluorescence
examination of LP shows colloid bodies in the papillary dermis, staining for
complement and immunoglobulins, particularly IgM. An irregular band of fibrin
is present along the basal layer in most cases. Often there is irregular
extension of the fibrin into the underlying papillary dermis).

Lichen nitidus eruption is found on any part of the body but the sites of predilection are the forearms, penis, abdomen, chestand buttocks.

Early, tiny LP papules may be clinically and histopathologically
indistinguishable from lichen nitidus. Coexistence with LP is common. It might
also be associated with atopic dermatitis.

It has been suggested that cases reported in the past as
summertime actinic lichenoid eruption (SALE) should be reclassified as actinic
lichen nitidus, also called “pinpoint, papular polymorphous light eruption”
(PMLE).

Lichen nitidus has followed hepatitis B vaccine and appeared during
treatment of hepatitis with interferon-α.

There is not usually an associated systemic condition but
associations with some conditions such as Down’s syndrome have been reported. Functional
impairment in cellular immunity has been reported in generalised lichen nitidus
and lichenoid photo-eruption similar to lichen nitidus has been associated with
HIV infection.

No genetic factors of the disease have been identified; however,
familial presentation might be seen. Most cases occur in children or young
adults. Its course is unpredictable; it may clear in a few weeks or last a very
long time, and may show little or no response to treatment.

Lichen nitidus following hepatitis B vaccine

The lesions are minute shiny flesh coloured papules but can be
reddish with various tints.

Saturday, 11 October 2014

A herald is a sign
that something is soon going to happen and the herald patch (mother patch) of pityriasis
rosea is a solitary larger and more conspicuous patch that precedes other
patches. The herald patch and the succeeding patches are similar
histopathologically (mild psoriasiform hyperplasia; spongiosis and exocytosis
of lymphocytes leading to ‘mini-Pautrier simulants’ simulating Pautrier
microabscesses because of the aggregation of lymphocytes; focal parakeratosis).
The interval is usually a week or so, but may be as short as a few hours or as
long as 2 months. This is a characteristic
evolutionary sequence seen in this skin condition that is believed to be due to
reactivation of HHV-6 and/or HHV-7. The incidence is highest between the ages
of 15 and 40, and the disease is most prevalent in the spring and autumn/winter. Females
are more frequently affected than males. The herald patch is absent or undetected in
about 20% of cases. Rarely, there may be more than one herald patch. The mother patch may be the sole manifestation of the disease! The reported epidemiological evidence for infectivity of pityriasis rosea includes occasional family or household outbreaks, seasonal and year-to-year fluctuations and statistical evidence for clustering in space and time. Interestingly, clusters of cases of herpes zoster have also been reported, and it is suggested that exposure to exogenous varicella zoster virus may trigger reactivation of latent virus in such circumstances.

The herald patch is
a sharply defined oval or round salmon-red patch or slightly raised plaque with
a marginal collarette of scale attached inside the periphery, with the free edge of the
scale internally. Actually, the word collarette is used because the scale
is attached inside the periphery and loose towards the centre of the lesion. The herald patch
rapidly reaches its maximum size, usually 2–5 cm in diameter but occasionally
much larger. The scales are silvery grey. The centre tends to clear and assumes
a tawny colour. When stretched across the long axis, the scale tends to fold
across the line of stretch, the “hanging curtain” sign. The herald patch is
usually on the thigh or upper arm, the trunk, suprapubic skin, the groin or the
neck; rarely may it be on the face, scalp or the penis.

The succeeding
patches (resembling the mother patch or being non-scaly) begin to appear in crops at 2 to 3-day intervals over a week or so. Less
often, new lesions continue to develop for several weeks. The long axes of the
lesions characteristically are parallel to the ribs on the upper chest and
back. There may be slight or moderate itching. The eruption is usually
generalized, affecting chiefly the trunk and sparing sun-exposed surfaces but
involvement of the face and scalp is quite common, especially in children.
Palms and soles are rarely involved. The eruption may be limited to a few
lesions, often around the herald patch. At times, the eruption is confined to a
single region, or may be maximal on the extremities almost sparing the trunk. An inverse distribution, sparing covered
areas, is not rare. Unilateral pityriasis rosea has been reported. When irritated lesions my develop vesicles

Although pityriasis
rosea is twice as common in black individuals as white, the same seasonal peaks
and preceding herald patch occur. However, in black skin, individual lesions
are smaller and more papular (micropapular) often urticated and may even be
vesicular. An inverse distribution of pityriasis rosea is more frequent in black
skin and involvement of the face is seen in 30%, especially in children. The
scalp is also more often affected. Lesions in black patients tend to be quite itchy
and are more persistent.

Chuh has drawn up a
list of diagnostic criteria for pityriasis rosea. Essential features for the
diagnosis include: (i) discrete circular or oval lesions; (ii) scaling on most
lesions; and (iii) collarette scaling with central clearance of at
least two lesions. Optionalclinical features of which one must also be
present include: (i) truncal and proximal limb distribution, with less than 10%
of lesions distal to the mid-upper arm and mid thigh; (ii) distribution of most
lesions along the ribs; and (iii) a herald patch appearing at least 2 days
before the generalized eruption. Histopathological features were not added to the
criteria, being relatively non-specific. However, Weedon states that histopathological features
are sufficiently characteristic to allow the diagnosis to be made. Moreover, histopathological
evaluation can be especially helpful in excluding the conditions with which
pityriasis rosea may be confused.

Without treatment,
the disease duration usually varies between 4 and 10 weeks. A few persist for
as long as 3 months. A longer duration, except in localized forms, is very
unusual. There may be temporary hyper- or hypopigmentation, but usually the
lesions vanish without trace. Postinflammatory hyperpigmentation occurs in
almost half of black patients, but hypopigmentation may also occur. Rarely,
a partial or complete relapse of a fading pityriasis rosea may be
seen. Second attacks occur in about 2% of cases. Pityriasis rosea during pregnancy is of concern (miscarriages and premature deliveries have been reported).

Pityriasis rosea may
be atypical in the appearance or distribution of the lesions or in its course. Examples include erythema multiforme-like variants, classic lesions admixed with follicular papules or purpura, and papular pityriasis rosea (absent herald patch). Thus the diagnosis can be challenging. In the typical,
fully developed case, the diagnosis is usually straightforward, as the
distribution, morphology and the usual absence of constitutional symptoms are
sufficiently distinctive. In pityriasis circinata et marginata of Vidal,
sometimes regarded as a special form of pityriasis rosea and seen mainly in adults,
the lesions are few and large, and are often localized to one region of the
body, especially the axillae or groins. They tend to become confluent and may
persist for several months. This form may follow a typical generalized
pityriasis rosea, but it usually occurs alone. Pityriasis rosea might mimic other
viral exanthema. Ackerman used to propose that pityriasis rosea and erythema
annulare centrifugum are clinical variations of a single pathological process,
and that pityriasis rosea gigantea is pityriasis rosea concurrent with erythema
annulare centrifugum.

Seborrhoeic
dermatitis may be pityriasiform (pityriasiform type of seborrhoeic dermatitis).
There is no herald patch. The lesions often develop slowly and the are more widely
distributed; being most numerous on the upper trunk near the midline, on the
neck and in the scalp, and they are duller in colour with thicker and greasier
scales. Small, scaly, follicular papules may also be present. The eruption is
persistent if untreated.

Some patterns of
drug eruption may have to be excluded. An acute onset without a herald patch,
itching and a tendency for the lesions to become lichenoid in appearance are
suggestive features. A progressive, irritable, atypical pityriasiform eruption
in a patient taking a drug, which is known to provoke reactions of this nature,
can be provisionally accepted.

Guttate psoriasis
and pityriasis lichenoides may sometimes need exclusion. In both, the lesions
are papular and persistent. In psoriasis they are surmounted by thicker silvery scales.
In pityriasis lichenoides they are polymorphic, some showing haemorrhagic crusting
and some adherent thicker scales.

The hypopigmented
patches with dry, branny scales of pityriasis alba are most frequent on the
face, and are seen mainly in young children. Discoid dermatitis has no collarette of scale and is usually not oval. Tiny vesicles are common.

The acute urticarial
forms in childhood can sometimes not be identified with complete certainty on
first examination unless a herald patch can be discovered. Re-examination after
2 days enables a confident diagnosis to be confirmed.

The herald patch and
the localized forms such as pityriasis circinata et marginata of Vidal can be
easily confused with ringworm. The lesions of ringworm are red and oedematous, may show marginal vesiculation and are usually not oval. Scale is usually at the periphery of plaques rather than inside the periphery. The pigmented form of pityriasis versicolor
does not show marginal scaling. In case of doubt microscopic examination of
scales is performed to differentiate these two conditions.

Scabies and lichen planus
may be confused with the papular type of pityriasis rosea.

If itch is
troublesome, or the appearance distressing, a topical steroid, usually of
moderate strength can be helpful. The standard dose regimen of aciclovir is
ineffective, but high-dose acyclovir (herpes zoster treatment dosage),
used early after the onset of the eruption, may lead to a more rapid clearance
of skin lesions. It has been stated in Fitzpatrick’s Dermatology in General
Medicine textbook that this form of therapy should be considered in
pityriasis rosea patients presenting early in their disease course who
demonstrate associated flu-like symptoms and/or extensive rash.

Herald patch

The centre tends to
clear and assumes a tawny (brownish-yellow) colour, with a marginal collarette
of scale attached inside the periphery, with the free edge of the scale loose internally.

Monday, 22 September 2014

Fixed drug eruption
(FDE) appearing few hours after ingestion of a tetracycline. FDE lesions
usually develop 30 minutes to 8 hours after drug intake. On continuing the
course the involved site flared with each exposure. He first ingested a
tetracycline a year ago without having a drug eruption. What is this period
called? Positive patch test reactions
are observed at the site of previous lesions harbouring significant numbers of
intraepidermal CD8+ T cells with an effector–memory phenotype. What is the
refractory period in this regard? What is non-pigmenting FDE? What is wandering
FDE?

Wednesday, 17 September 2014

Becker’s naevus is a relatively common anomaly, affecting most
racial groups, and about five times more frequent in males than females. The
basal and suprabasal keratinocytes are heavily pigmented, and melanocyte
density is variably reported as increased or normal, with a few melanophages in
the upper dermis. There are no junctional or intradermal naevus cells. It may
present in childhood, but is usually first noticed during adolescence,
initially pale in colour and becoming more conspicuous after sun-exposure.
Classically, Becker naevus is unilateral but it is rarely bilateral. The usual
site is shoulder, anterior chest or scapular region, but lesions may occur on
any area of the body. It starts as an area of irregular macular pigmentation,
which spreads to a diameter of several centimetres, new macules developing
beyond the margin and fusing with it, giving a geographical contour. The skin
may thicken towards the centre of the lesion. Increased terminal hairs may
appear on and around the lesion.Becker’s naevus has been reported to follow
Blaschko’s lines, but the usual lack of conformity to Blaschko’s lines may be
due to the relatively late occurrence of a causative mutation. The mutant skin
clone is presumably predisposed not only to pigmentation but also to androgen
sensitivity, since Becker’s naevus is prone to acne and hypertrichosis (increased
expression of androgen receptors within lesional skin). Many dermatologists
would not regard Becker’s naevus as an epidermal naevus. Once present, Becker’s naevus remains indefinitely.
Almost all epidermal naevi follow the pattern of lines documented by
Blaschko from drawings of epidermal naevi. The pattern is attributed to
the lines of migration and proliferation of epidermal cells during
embryogenesis. The lines do not correspond to any known nervous, vascular or
lymphatic structures. The bands of abnormal skin represent clones of cells
carrying a mutation in a gene expressed in the skin. Mosaicism impact on the
phenotype relates to the proportion of cells that harbour the mutation and
their distribution. Mosaic describes an art form in which pictures are produced
by joining together tiny pieces of different coloured stone or glass. The term
is used in genetics to describe individuals composed of cells of different
genotypes, such as patients with Turner syndrome who have both 45, XO and 46,
XX cells. The pattern may vary according to cell type and timing of mosaicism.
In the skin, genetic mosaicism classically appears as Blaschko's lines. The
term "pigmentary mosaicism" encompasses different phenotypic
expressions of common pathogenic process caused by genetic mosaicism that
specifically disrupt expression of pigmentary genes.

Cutaneous conditions have been reported to colocalize with
Becker’s naevus and include e.g. pityriasis versicolor (I have seen one case),
granuloma annulare and lichen planus. The term Becker’s naevus syndrome has been proposed to describe
the association of a Becker’s naevus with ipsilateral non-cutaneous abnormalities.

A well-developed Becker’s naevus is unmistakeable.

Differential diagnosis of less developed lesions includes:

Progressive cribriform and
zosteriform hyperpigmentation: This might be a non-hypertrichotic variant of
Becker’s naevus or a localised form of linear and whorled naevoid
hypermelanosis.

(Diffuse) linear and whorled naevoid
hypermelanosis.

Idiopathic eruptive macular
hyperpigmentation: The lesions disappear gradually over several months to
years.

Acquired smooth muscle hamartoma: It has
similar clinical and histopathological features, but in different proportions,
with less pigmentation and more smooth muscle. Lesions described in the
literature as ‘congenital Becker’s naevi’ could have actually been congenital
smooth muscle hamartomas. However, it is possible that in some cases there is
clinical/histopathologic overlap with Becker’s naevus.

Partial unilateral lentiginosis/agminated lentiginosis: Two similar conditions if not identical.

Wednesday, 3 September 2014

Epidermodysplasia verruciformis (EV) is a rare inherited susceptibility
to widespread and persistent infection with specific HPV genotypes giving rise
to plane warts, pigmented warts, pityriasis versicolor–like lesions and
seborrhoeic keratoses-like lesions. It is inherited as an autosomal recessive
trait, though autosomal dominant and X-linked patterns have been
reported. The susceptibility for EV was localised to chromosome 17q25 and mutations in EVER1 and EVER2 genes from the same region were identified. There is a failure to mount an effective immune response to the HPV infection hence the recurrence after treatment. The lesions usually develop rapidly in childhood but may first appear
at any age. They are most numerous on the face and neck and backs of the hands
and feet, and may be restricted to these sites, but there are often scattered lesions
elsewhere and the lesions may be generalized over the entire body surface. EV
is remarkably persistent and may remain unchanged for decades. However, slow
spontaneous regression has been reported.Carcinomas develop mainly in sun-exposed lesions* suggesting
that ultraviolet radiation is an important factor.Viral
particles can be identified ultrastructurally not only in the spinous cells, but
also in basal cells. EV HPV may be required only in early phases of
carcinogenesis and therefore may not be found in well-developed cancer. Skin cancers are less common in African
patients, suggesting a protective effect of skin pigmentation. EV-like lesions have been observed in the
setting of immunosuppression and are sometimes called acquired EV. Remission of
EV-like eruptions can occur in HIV infected patients after the commencement of
highly active antiretroviral therapy. In addition to the host genetic background, the EV-HPVs are activated by UV exposure and immunosuppression.

Strict sun avoidance and protection should be started as soon as
the syndrome is diagnosed. Diligent use of an effective sunscreen should be
advised. An approach similar to that for patients with xeroderma pigmentosa can be instituted.No specific treatment exists for EV lesions. Therapy with
electrodesiccation, cryotherapy, topical retinoids, and surgery are generally
unsatisfactory. Mixed results have been seen with topical 5% imiquimod cream. Many
other therapies have been tried e.g. oral retinoids, oral cimetidine and
topical vitamin D analogues. Whether dysplastic or malignant change can be prevented by oral retinoids is unknown. If skin grafting is required, the grafts should be
taken from sun-protected skin, such as the buttocks or inner upper arm.

Friday, 15 August 2014

Trachyonychia (Gk trachys rough, onychos nail)presents as
a rough surface affecting the entire nail plate in up to 20 nails. Thus trachyonychia
may involve one, several or all digits and when most or all digits are
involved, the term twenty-nail dystrophy is commonly used. Trachyonychia may
affect patients from all age groupsalthough it is most commonly diagnosed in children. Familial
forms exist. Spontaneous resolution might occur.

Based on appearance, trachyonychia is divided into two types*: (1)
Opaque trachyonychia where nail is ridged and rough, and is deprived of its
natural lustre. The nail appears sandpapered in a longitudinal direction
(severe trachyonychia). (2) Shiny trachyonychia where the nail plate is shiny
with numerous, closely aggregated, small superficial pits. This shiny
appearance may be accentuated by a camera flash or by tangential light from a
pen-torch (mild trachyonychia). The severity of trachyonychia frequently varies
from nail to nail and the shiny and opaque varieties of the disease may coexist
in the same patient.

The most common presentation is as an isolated nail abnormality
(idiopathic) where histopathology shows spongiosis and a lymphocytic infiltrate
of the nail matrix. It can be associated withpsoriasis (pitting of the fingernails
may be the only manifestation for months or even years), alopecia areata,
lichen planus (it may be its sole manifestation and some regard nail lichen planus
as a distinct condition) and other conditions. Unilateral involvement may occur
in complex regional pain syndrome. Localized trachyonychia in a judo player** from the repeated grabbing of opponents’ uniforms has been described. Routine
biopsy is not recommended.

Treatment is often useless and several forms have been
suggested. Tazarotene alone or in association with topical steroids may improve
the condition. The safety of tazarotene has not been established in patients under the age of 18 years.

Sunday, 3 August 2014

Plamar lichen planus can be difficult to diagnose if present as
an isolated finding. Itchy (or painful)
erythematous scaly plaque is characteristic. The lesions tend to be firm and
rough with a yellowish hue. It is one of the therapy-resistant variants of lichen
planus.Although lesions on the volar aspect
of the wrists are common, lesions on the adjacent palms are less common and lack
the characteristic shape and colour of lesions elsewhere. They may be broadly sheeted or show up as
punctate keratoses. Vesicle-like papules are recorded. Itching may be absent. Palmoplantar
lichen planus may also present as erosive-ulcerative type. When such changes
occur in isolation, diagnosis is difficult; and conditions such as eczema,
tinea, secondary syphilis, psoriasis, porokeratosis, callosities and warts must
be excluded. Histopathologically findings are identical to those of classic
lichen planus.

The primary lesions of lichen planus are characteristic, almost
pathognomonic violaceous, flat-topped, polygonal papules. Papules expand to
plaques. The colour of the lesions initially is erythematous but well-developed
lesions are violaceous, and resolving lesions are often hyperpigmented. The surface
is shiny with scant adherent scales. On the surface, grey or white lines, known
as Wickham’s striae, may traverse the surface of the papules. Dermoscopy may
enhance the visualization of this important diagnostic element. Most patients react to the itching of lichen
planus by rubbing rather than scratching but itching can be absent. The four Ps-purple,
polygonal, pruritic papule are a mnemonic to help you recall the findings that
characterise lichen planus. The centre of the papule shows irregular
acanthosis of the epidermis, irregular thickening of the granular layer, and
compact hyperkeratosis. A focal increase in thickness of the granular layer and
infiltrate corresponds to the presence of Wickham’s striae. The basal damage is
associated with a band-like infiltrate of lymphocytes and some macrophages
which press against the undersurface of the epidermis. Occasional lymphocytes
extend into the basal layer. The infiltrate however does not obscure the
interface or extend into the mid-epidermis. Pigmentary incontinencewith dermal
melanophages is characteristic.Postinflammatory
pigmentation may persist for some time.

Potent topical corticosteroids (with or
without occlusion) remain the treatment of choice for lichen planus in patients
with classic and localized disease.

Improvement after use of very potent topical corticosteroid with occlusion

Thursday, 31 July 2014

Varicella occurs throughout the world but infection occurs at a
younger age in temperate zones compared to the tropics. In temperate regions more
than 90% of adults are immune to varicella while in tropical countries only 60%
of adults are immune to it. Transmission is via the respiratory route and less commonly
by direct contact with the lesions. A susceptible person may develop varicella
following exposure to the lesions of herpes zoster. The severity of the disease
is age-dependent, with adults having more severe disease and more complications.
Varicella confers lasting immunity and second attacks are uncommon, especially
in immunologically healthy people, but clinical reinfection with a mild
varicella-like illness occasionally takes place.

The distinctive features of varicella are the centripetal distribution,
the polymorphism in each affected site and the rapid progression of the individual
lesion from vesicle to crust. Vesicles are common in the mouth, especially on
the palate, and are occasionally seen on other mucous membranes, including the
conjunctiva and genitalia. On the anal mucosa they may be followed by painful
ulcers.

Aciclovir is indicated for varicella in adults
and for severe varicella at any age in the immunocompromised. Therapy does not appear to alter the development of adequate
immunity to reinfection.

Centripetal distribution

Resolving rash. The virus is transmitted by droplet infection from the
nasopharynx. A brief first viraemic stage, when the virus can disseminate to
other organs, is followed by a second viraemia coinciding with the onset of the
rash. Patients are infectious to others from about 2 days before to 5 days
after the onset of the rash and most non-immune people will contract the
infection if exposed to someone in the infectious stage of varicella. Vesicle fluid
contains a large amount of virus. Completely dry scabs are not infectious.

A characteristic feature is the presence of lesions at different
stages in each site. Papules very rapidly become vesicles that appear over around 4 days with centripetal distribution. Vesicles dry rapidly to become crusts within around 4 days. Crusts soon separate leaving shallow pink depressions that normally heal without scarring within around 2 weeks. Hyper- or hypopigmentation may persist for weeks and scars can occur in some.

Sunday, 20 July 2014

The evidence that pityriasis rosea is a viral exanthem
associated with reactivation of HHV-6 and/or HHV-7 is strong. Based on this
concept, trials of antiviral drugs have been reported. The standard dose regimen
of aciclovir is ineffective, but high-dose acyclovir (herpes zoster treatment
dosage), used early after the onset of the eruption, may lead to a more rapid
clearance of skin lesions. Here, the rash began to resolve soon after starting
high-dose aciclovir (second photo taken at 2 weeks of starting aciclovir therapy). Without treatment, the disease duration
usually varies between 4 and 10 weeks. Rarely, a partial or complete relapse of a fading pityriasis rosea may be seen. Second attacks occur in about 2% of cases.
Interestingly, pityriasis rosea has been classified in Rook’s textbook of
dermatology as a viral infection for many years before a viral cause was actually
found. It has been stated in Fitzpatrick’s Dermatology in General
Medicine textbook that this form of therapy should be considered in pityriasis
rosea patients presenting early in their disease course who demonstrate associated
flu-like symptoms and/or extensive rash.

Before treatment

Two weeks of starting treatment

The eruption is usually generalized, affecting chiefly the trunk
and sparing sun-exposed surfaces but involvement of the face and scalp is quite
common, especially in children. An inverse distribution, sparing covered areas,
is not rare.

My About.Me

The Royal College of Physicians and Surgeons of Glasgow (RCPSG) Coat of Arms Symbolism

The RCPSG (a charity) was established by Royal Charter from King James VI of Scotland (James I of England) in 1599.

*The first and fourth quarters of the shield contain the lancet that represents the surgeons, and poppy that represents the laudanum used by the physicians and the snake-entwined staff that represents Aesculapius, Greek god of medicine.

*The second quarter of the shield contains the Royal Arms of Scotland (the lion of Scotland) and reflects the gift of the original charter from King James VI of Scotland (James I of England).

*The third quarter has the familiar arms of the City of Glasgow, reflecting the College's origins in Glasgow and the West of Scotland. There are the tree that never grew, the bird that never flew, the bell that never rang and the fish that never swam.

*The supporters are Hygeia (goddess of health) on the right, and on the left, Minerva (goddess of art and science).

*The crest is an antique lamp on an open book, which symbolises the light of learning dispelling the darkness of ignorance.

*The coat of arms has two mottoes. Above is "Conjurat Amice", translated as "We live together in amity". This reflects the unique nature of the RCPSG in encompassing physicians and surgeons, whereas those of Edinburgh and London are separate. The motto below the shield reads "Non vivere sed valere vita". It is an epigram of the Roman poet Martial and can be translated into English as "Not simply to live but to enjoy life".

Current Forms of Assessing Trainees (Dermatology, Venereology and Surgical Andrology)

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I cannot be held responsible for any consequences arising from the use of information contained in this publication.It is the ultimate responsibility of the medical practitioner to determine the best treatment for each patient.